What factors can hinder effective coughing? 1. Artificial airways 2. Neuromuscular disease 3. Systemic overhydration 4. Pain or fear of pain

a. 1, 2, and 4 only
b. 2 and 4 only
c. 1 and 3 only
d. 3 and 4 only

ANS: A
Some patients with advanced chronic obstructive pulmonary disease or severe restrictive disor-ders (including neurologic, muscular, or skeletal abnormalities) may not be able to generate an effective spontaneous cough. Likewise, pain or fear of pain caused by coughing may limit the success of directed cough. Systemic dehydration, thick, tenacious secretions, artificial airways, or the use of central nervous system depressants can thwart efforts to implement an effective di-rected cough regimen.